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When a California worker is injured on the job and files a workers’ compensation claim, one of the most pivotal steps in the process can be the Qualified Medical Evaluator (QME) examination. The QME process is intended to resolve disputes between the injured worker and the claims administrator regarding the injury’s nature, extent, or cause. However, this process can be confusing and intimidating, especially if you’re dealing with pain, medical treatment, or stress about returning to work.
At Hanning & Sacchetto, LLP, our workers’ compensation attorneys in Whittier guide injured workers through every workers’ compensation system phase, including the QME process. Here’s what you need to know to protect your rights and ensure your voice is heard.
What Is a Qualified Medical Evaluator (QME) and When Do You Need One?
When there is a disagreement between you and the insurance company about your injury, a QME is brought in to provide a neutral, independent medical evaluation. These disputes might involve whether your injury is work-related, the severity of your condition, or whether you’ve reached maximum medical improvement (MMI).
You may need a QME if:
- The insurance company disputes your workers’ compensation doctor’s opinion.
- Your claim was denied, and you’re trying to prove it’s valid.
- There’s a question about your ability to return to work or the level of permanent disability.
The QME does not treat you; instead, it examines you and produces a medical-legal report that can significantly influence the outcome of your claim.
How to Request a QME in California
When a dispute arises, you or the insurance company can request a QME panel from the California Division of Workers’ Compensation (DWC). This panel includes three randomly selected doctors certified QMEs in the appropriate specialty. You must choose one doctor from the panel within 10 working days of receiving the list, or the insurance company may choose for you.
Timing and accuracy are critical here. Failing to respond on time, choosing an inappropriate specialty, or overlooking necessary paperwork can affect your claim. Having a knowledgeable attorney on your side can make a significant difference.
What to Expect During Your QME Evaluation
The QME appointment may feel like a standard medical exam, but it’s much more formal and carries legal weight.
The QME will:
- Ask detailed questions about your injury, symptoms, and treatment history.
- Review medical records, diagnostic tests, and imaging.
- Assess your ability to perform work-related tasks.
- Evaluate whether your condition has stabilized or is likely to improve.
Be honest, thorough, and consistent in your answers. The QME’s report will be sent to the claims administrator and can affect your eligibility for benefits, including temporary and permanent disability payments.
What Happens After the QME Report is Issued?
Once the report is completed, you and the insurance company receive a copy. The QME’s opinion on medical issues, such as diagnosis, impairment rating, work restrictions, and need for future care, can be used to settle the claim or serve as evidence in a workers’ compensation hearing.
If you disagree with the QME’s findings, you may be able to challenge the report through the legal system or request a supplemental evaluation, but the rules for doing so are strict and time-sensitive.
Protecting Your Rights Throughout the QME Process
The QME process can have a lasting impact on your workers’ compensation benefits. Injured workers may unknowingly weaken their claims without proper guidance or miss critical deadlines.
At Hanning & Sacchetto, LLP, our experienced Los Angeles County workers’ compensation attorneys are here to protect your rights and advocate for your best interests. We help injured workers prepare for QME exams, select the right specialists, and respond to unfair or inaccurate evaluations. Call (562) 280-2095 or contact us online.
Let us help you confidently navigate the QME process and secure the benefits you deserve.
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